NCLEX NCLEX Certifications NCLEX-RN Questions & Answers

• Question 181:

  The nurse is admitting an infant with bacterial meningitis and is prepared to manage the following possible effects of meningitis:

  A. Constipation

  B. Hypothermia

  C. Seizure

  D. Sunken fontanelles

  Correct Answer: C

  (A) Constipation may occur if the child is dehydrated, but it is not directly associated with meningitis. (B) It is more likely the child will have fever. (C) Seizure is often the initial sign of meningitis in children and could become frequent. (D) It is more likely the child will have bulging fontanelles.

• Question 182:

  A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to:

  A. Place her in knee-chest position during the contraction

  B. Use effleurage during the contraction

  C. Apply strong sacral pressure during the contraction

  D. Have her push with each contraction

  Correct Answer: C

  (A) This measure is inappropriate. The knee-chest position is employed to take pressure off the cord. (B) Effleurage is a comfort measure but not the one that will contribute most to the relief of backache caused by a posterior position. (C) Sacral pressure will counteract the pressure created by the position of the fetal head. (D) The client is not completely dilated. Pushing is contraindicated until the second stage of labor.

• Question 183:

  A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:

  A. Evidence of perineal irritation

  B. Pulse fell from 102 to 96

  C. Pulse increased from 96 to 102

  D. Temperature rose to 102_F rectally

  Correct Answer: D

  (A) Perineal irritation needs to be addressed, but it is probably not necessary to call the physician. (B) This fall in pulse rate remains within normal limits and is probably insignificant. It is important to monitor for continued change. (C) This rise in pulse rate is probably not significant, but it is important to monitor for continued change. (D) This temperature is above normal limits and needs medical investigation. It may or may not be related to the head injury.

• Question 184:

  A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:

  A. Blood pressure increase from 100/80 to 115/85 after lunch

  B. Headache that is unresponsive to acetaminophen (Tylenol)

  C. Pulse rate ranges between 68 bpm and 76 bpm

  D. Temperature rise to 102_F rectally

  Correct Answer: D

  (A) This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood pressure. (B) Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask neurological signs and may depress the CNS. (C) Pulse rates between 68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in pulse rate, which is a late sign of increasing ICP. (D) An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the head injury, but CNS infection is serious and difficult to control.

• Question 185:

  Blood work reveals the following lab values for a client who has been diagnosed with anorexia nervosa: hemoglobin 9.6 g/dL, hemocrit 27%, potassium 2.7 mEq/L, sodium 126 mEq/L. The greatest danger to her at this time is:

  A. Hypoglycemia from low-carbohydrate intake

  B. Possible cardiac dysrhythmias secondary to hypokalemia

  C. Dehydration from vomiting

  D. Anoxia secondary to anemia

  Correct Answer: B

  (A) There is no lab data to support hypoglycemia. (B) Hypokalemia, caused by vomiting and decreased dietary intake of potassium, can result in life-threatening dysrhythmias. (C) Evidence of dehydration is not life threatening at this time, although fluid volume deficit does need to be addressed. (D) The client's hemoglobin does not reflect a life threatening value sufficient to render the client anoxic.

• Question 186:

  When discussing the relationship between exercise and insulin requirements, a 26-year-old client with IDDM should be instructed that:

  A. When exercise is increased, insulin needs are increased

  B. When exercise is increased, insulin needs are decreased

  C. When exercise is increased, there is no change in insulin needs

  D. When exercise is decreased, insulin needs are decreased

  Correct Answer: B

  (A) If the client's insulin is increased when activity level is increased, hypoglycemia may result. (B) Exercise decreased the blood sugar by promoting uptake of glucose by the muscles. Consequently, less insulin is needed to metabolize ingested carbohydrates. Extra food may be required for extra activity. (C) This statement directly contradicts the correct answer and is inaccurate. (D) When exercise is decreased, the client's insulin dose does not need to be altered unless the blood sugar becomes unstable.

• Question 187:

  The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is:

  A. 900 mL/24 hr

  B. 1300 mL/24 hr

  C. 1600 mL/24 hr

  D. 2000 mL/24 hr

  Correct Answer: C

  (A, B, D) These values are incorrect. Normal intake for a child of 2 years is about 1600 mL in 24 hours. (C) This value is correct. Normal intake for a child of 2 years is about 1600 mL in 24 hours.

• Question 188:

  A client suspected of having anorexia nervosa is placed on bed rest with an IV infusion and a high-carbohydrate liquid diet. Within 72 hours, the results of her lab work show a return to normal limits. She is transferred to the psychiatric service for further treatment. A behavior modification plan is initiated. Three days after her transfer, the client tells the nurse, "I haven't exercised in 6 days. I won't be eating lunch today." This statement by her most likely reflects:

  A. Her lack of internal awareness about the outcome of the behavior

  B. Increased knowledge about personal exercise plans

  C. A manipulative technique to trick the nurse into allowing her to miss a meal

  D. A true desire to stay fit while in the hospital

  Correct Answer: A

  (A) Indirect self-destructive behavior such as that seen in anorexia nervosa is characterized by the client's lack of insight and the awareness that the outcome of the dieting, exercising, and weight loss will ultimately result in death if uninterrupted. (B) Although the client is knowledgeable about exercise, knowledge about the balance between nutrition, exercise, and rest is absent. (C) The client's level of denial and lack of awareness disallow this behavior as a manipulative trick. (D) The client's illness-maintaining behaviors are inconsistent with fitness.

• Question 189:

  A 28-year-old multigravida has class II heart disease. At her prenatal visit at 34 weeks' gestation, all of the following observations are made. Which would require intervention?

  A. Weight gain of 2 kg in 4 weeks

  B. Blood pressure of 128/78

  C. Subjective data: shortness of breath after showering

  D. Ankle edema reported present in late afternoon and evenings

  Correct Answer: C

  (A) This is not an excessive weight gain indicative of fluid retention. (B) The blood pressure is within normal range. (C) Showering should not cause shortness of breath. This could be a sign ofcardiac decompensation. (D) Dependent ankle edema is normal late in the day among pregnant women. Progressive edema would be a dangerous development.

• Question 190:

  On admission to the postpartal unit, the nurse's assessment identifies the client's fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likely an indication of:

  A. Normal involution

  B. A full bladder

  C. An infection pain

  D. A hemorrhage

  Correct Answer: B

  (A) Immediately after expulsion of the placenta, the fundus should be in the midline and remain firm. (B) A boggy displaced uterus in the immediate postpartum period is a sign of urinary distention. Because uterine ligaments are stretched, a full bladder can displace the uterus. (C) Symptoms of infection may include unusual uterine discomfort, temperature elevation, and foul-smelling lochia. The stem of this question does not address any of these factors. (D) While excessive bleeding is associated with a soft, boggy uterus, the stem of this question includes displacement of the uterus, which is more commonly associated with bladder distention.